Management Of Patients Research Articles

Acute Diarrhea in a Tertiary Emergency Department: From Readmission Determinants to Antibiotic Prescription

Acute diarrhea represents a major public health issue, and the management of adult patients admitted to the emergency department (ED) for this problem is still challenging. In a retrospective analysis on more than 20,000 patients visiting a tertiary ED for acute diarrhea and then being discharged home, we found that age > 65 years, onset of symptoms > 24 h since ED admission, refusal of hospitalization, and a history of chronic renal and liver diseases were independently associated with ED readmission for abdominal symptoms within 7 days. In the younger group, the presence of comorbidities significantly impacted on ED readmission, while fever and alteration of serum creatinine were the main determinants in the older group. Antibiotics were prescribed in about 25% of patients, although diarrhea etiology (viral or bacterial) was usually not available. According to international guidelines, fluoroquinolones were the most prescribed class, showing an inverse correlation to ED readmission. However, β-lactams and probiotics were also commonly prescribed; the latter were independently correlated to ED readmission in the elderly group. A comprehensive, guideline-based approach, including a detailed clinical history and laboratory and comorbidity assessment, should be encouraged to support physicians in the management of different age subgroups of adults admitted to the ED for acute diarrhea.

A lipidomics-based method to eliminate negative urine culture in general population.

This study employs a lipidomics-based method that promises to enhance the accuracy and reliability of urine culture diagnostics within 1 hour of sample collection. Our findings underscore the potential of lipidomics as a valuable tool in identifying and characterizing microbial populations present in urine samples and efficiently rule out negative urines, ultimately leading to improved patient care and management of urinary tract infections.

Developing a Novel Prognostic Model Based on Muscle-Invasive Bladder Cancer Types: A Multicenter RetrospectiveCohort Study of Patients Who Received Radical Cystectomy and Chemotherapy.

To develop a prognostic model to manage patients with muscle-invasive bladder cancer (MIBC) undergoing radical cystectomy (RC) and chemotherapy. Clinicopathologic characteristics and survival data were collated from a North American database to develop a model. Genomic and clinicopathologic data were also obtained from European and Asian databases to externally validate the model. Patients were classified as either "primary" or "progressive" MIBC according to non-muscle invasive stage history. Optimized cancer-specific survival (CSS) models, based on MIBC types, were constructed using Cox's proportional hazard regression. Differences of biological function and tumor immunity, between two risk-based groups stratified according to the prognostic model, were estimated. There were 2631 participants in the American cohort, 291 in the European cohort and 142 in the Asian cohort. Under Cox's regression analysis, tumor stage, lymph node stage, age, ethnicity, and MIBC types were independent CSS predictors (all p < 0.05). The constructed nomogram, whichintegratedthese variables, improved the predictivepower. This model had good discrimination and calibration. Patients were categorized into high- or low-risk groups according to the total points calculated. Kaplan-Meier curves revealed that patients in the high-risk group had poorer survival (p < 0.001). This was confirmed with two external validation cohorts (both with p < 0.001). Higher stromal scores and increased M0 and M2 macrophage numbers were observed in samples from the high-risk group, whereas regulatory T cells had lower infiltration in these populations (all with p < 0.05). This MIBC type-based nomogram provides accurate CSS predictions, which could help improve patient management and clinical decision-making.

Immune Mechanisms and Biomarkers in Systemic Lupus Erythematosus

The immense heterogeneity of the chronic, inflammatory, autoimmune disease systemic lupus erythematosus (SLE), both with regard to immunological aberrancies and clinical manifestations, poses diagnostic difficulties and challenges in the management of patients [...]

Etiopathogenetic features of bone metabolism in patients with diabetes mellitus and Charcot foot

Diabetic neuropathy is one of the most common diabetes mellitus complications associated with mediocalcinosis of the lower extremities, a significant decrease in feet bone mineral density, and a high incidence of cardiovascular disease. In most cases, calcium-phosphorus metabolism changes occur in patients with diabetic neuroarthropathy, or Charcot foot, when we can observe feet local osteoporosis, which in 90% of cases associated with a vessel’s calcification of the lower extremities in the majority of diabetes population. A large number of studies presented literature have demonstrated that patients with Charcot foot can have accelerated bone metabolism and increased bone resorption. Patients with Charcot foot often have crucial abnormalities in the calcium-phosphorus parameters, bone metabolism, and levels of vitamin D and its metabolites. In addition, the duration of diabetes mellitus, the degree of its compensation widely affects the development of its micro- and macrovascular complications, which could also accelerate the development of mineral and bone disorders in these types of patients. Multifactorial pathogenesis of these disorders complicates the management of patients with a long and complicated course of diabetes mellitus. This review discusses the peculiarities of vitamin D metabolism, the importance of timely diagnosis in phosphorus-calcium disorders, and the specifics of therapy in these patients. Special attention is paid to the timely diagnosis of the Charcot’s foots acute stage based on the bone marrow edema by MRI evaluation and the possibility of reducing the immobilization period.

Concurrent Esophageal Leiomyoma and Helicobacter pylori Infection

Esophageal leiomyomas are rare benign tumors arising from smooth muscle cells in the esophagus. Despite their rarity, they present unique diagnostic and management challenges due to varied symptomatology and anatomical locations. Here, we present a case of a 40-year-old male with unresolved dysphagia and epigastric pain referred for esophagogastroduodenoscopy (EGD). EGD revealed a medium-sized submucosal mass at the gastroesophageal junction, partially obstructing the lumen. Concurrently, severe chronic active gastritis with Helicobacter pylori (H. pylori) infection was confirmed upon gastric biopsy. Subsequent evaluation included endoscopic ultrasound (EUS), which identified a likely benign esophageal leiomyoma. Although a surgical referral was recommended, the patient was deferred. This case highlights the importance of EGD in diagnosing esophageal leiomyomas and uncovering incidental findings that can significantly influence patient management. The rare presentation of this leiomyoma at the gastroesophageal junction, combined with the co-occurrence of severe H. pylori-induced gastritis and chronic GERD, introduces new considerations for understanding the pathophysiology of esophageal tumors. The rare combination of these factors highlights the need for further research into their interactions, providing novel insights that could influence future diagnostic strategies and therapeutic approaches for similar cases.

HbA1c Point-of-Care Testing and its Role in the Management of Diabetes

The San Joaquin Central Valley, known for its thriving agricultural industry, faces challenges related to low socioeconomic status, limited access to healthy food, and healthcare disparities. To enhance compliance among patients with diabetes, United Health Centers (UHC) implemented in-clinic HbA1c Point-of-Care Testing (POCT) to provide instant data for managing diabetes. The total number of patients with diabetes screened was 2,020 across three sites, with the total number of those in poor control totaling 825. Despite theorizing that these HbA1c machines would improve patient management, statistical analysis revealed no significant impact on diabetes control within the population. However, a closer examination of percentage data demonstrated clinical relevance across UHC sites. Initially, only one out of three UHC sites met the organization’s goal of keeping uncontrolled diabetic patient populations below 30%. After one year of POCT utilization, two out of three sites nearly achieved this goal, resulting in a 27% reduction in poorly managed diabetic patients. While the study’s duration may have limited statistical significance, further analysis and a longer study period could confirm the positive impact of HbA1c POCT on patient compliance.

응급구조학과 수업에서 빔(beam)을 이용한 동영상 교육과 QR code 동영상을 활용한 자가 학습의 자기효능감 비교 분석

Objectives The purpose of this study was to compare and analyze the impact of video practice education using beam technology and self-learning through QR code videos on the acquisition of emergency patient management skills in relation to self-efficacy. Methods The study was conducted from March 27, 2024, to March 31, 2024. It employed a randomized cross-pre-post-experimental design to assess the impact of emergency patient management skills on self-efficacy among 53 students enrolled in the Department of Paramedicine, using either beam technology or self-learning via QR code videos. Results The study found no significant difference in intravenous selection and insertion before training and during practical training using beams. However, there was a notable improvement in self-efficacy observed after viewing the QR code videos. Notably, participants who engaged in self-learning through QR code videos more than three times demonstrated the highest levels of self-efficacy, with a significant difference noted. Conclusions The findings suggest that learners enhanced their self-efficacy by repeatedly practicing difficult skill items through self-learning using QR code videos.

Role of sex and training characteristics on exercise effects on cardiovascular aging: protocol for a systematic review with meta-analysis of randomized trials

BackgroundCardiovascular diseases remain a leading global cause of mortality worldwide especially in older adults. Although it is known that regular exercise reduces cardiovascular diseases incidence, its effects on specific cardiovascular aging parameters considering the influence of sex and different exercise designs are still not fully understood. Therefore, this systematic review and meta-analysis aims to evaluate the effects of different physical exercise protocols on age-related cardiovascular outcomes in older adults.MethodsThis systematic review and meta-analysis will be reported in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Articles will be eligible if they are randomized controlled trials with a primary objective of evaluating the chronic effects of exercise interventions on cardiovascular aging parameters. Search strategy will be performed from the inception to September 30th, 2023, in the following electronic databases: MEDLINE (Ovid), SCOPUS (Elsevier), Embase, Sport Discus (EBSCO), Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science Core Collection (Clarivate Analytics). Data will be extracted and managed through Research Electronic Data Capture (REDCap) software. The Tool for the assEssment of Study qualiTy and reporting in EXercise (TESTEX) will be used to assess the methodological quality of included studies. Additionally, the quality of the findings will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) profiler. Meta-analysis based on the random-effects model will be performed (if deemed suitable, considering the methodological and clinical heterogeneity of the studies) to estimate the effects of exercise training on cardiovascular aging variables (i.e., cardiac output; arterial stiffness; stroke volume; endothelial function; and carotid intima-media thickness). Heterogeneity will be assessed with the I2 statistics, while the publication bias will be assessed based on Egger’s test.DiscussionTo the best of our knowledge, this will be the first systematic review and meta-analysis to investigate the impact of sex and training protocols on the cardiovascular aging parameters. Moreover, the findings of this systematic review and meta-analysis will provide evidence for health professionals in the management of elderly patients in order to optimize the exercise prescription to face the cardiovascular alterations related to the aging process, considering the effects of different protocols according to sex.Systematic review registrationPROSPERO CRD42023441015 .

Fluids, Vasopressors, and Inotropes to Restore Heart–Vessel Coupling in Sepsis: Treatment Options and Perspectives

Sepsis is a complex syndrome with heterogeneous clinical presentation and outcome, characterized by an abnormal inflammatory response, potentially leading to multiorgan damage and hemodynamic instability. Early resuscitation with fluids and timely control of the source of sepsis are key treatment targets in septic patients. Recommendations on when to add vasopressors and inotropes are mostly empirical and anecdotal, therefore remaining a topic of debate. This narrative review was developed to present and discuss current options in the early management of hemodynamic derangement induced by sepsis. We discuss the strengths and drawbacks of the recommended treatment with fluids and how to optimize volume resuscitation in order to avoid fluid overload or under-resuscitation. The choice and timing of vasopressor use represent hot topics in the early management of septic patients. We describe the advantages and limitations of the early introduction of vasopressors and new catecholamine-sparing strategies. We conclude with a description of the inotropes, considering that the heart plays a key role in the pathophysiology of septic shock.

Examining dietary interventions in Crohn’s disease

This editorial builds on the article by Shakhshir et al . We conducted an overview of evidence-based dietary interventions in adults with inflammatory bowel disease (IBD). In the IBD population, there may be a role for the Mediterranean diet due to its anti-inflammatory effects, long-term sustainability, and role in improving cardiovascular health. In active Crohn’s disease, the use of exclusive enteral nutrition, the Crohn’s disease exclusion diet, or the specific carbohydrate diet may be used as a short-term adjunct to medical therapy and may improve mucosal healing. The low-FODMAP diet can assist in reducing symptoms for patients without evidence of active bowel inflammation. As interest in nutritional therapy increases amongst clinicians and patients alike, it is integral that dietary therapies are understood and discussed in routine management of patients with IBD as part of holistic care, ideally through a multidisciplinary setting with involvement of experienced dietitians. This serves to improve clinician-patient engagement and reduce complications of IBD including micro and micronutrient deficiencies.

Dental management of patients with kidney disease in the Intensive Care Unit: an integrative review

Dental management of patients with kidney disease in the Intensive Care Unit: an integrative review

Thyroid Hormone and Alzheimer's: Bridging Epidemiology to Mechanism.

The identification of critical factors that can worsen the mechanisms contributing to the pathophysiology of Alzheimer's is paramount. Thyroid hormones (TH) fit this criterion. Epidemiological studies have identified an association between altered circulating TH levels and Alzheimer's. The study of human and animal models indicates that TH can affect all the main cellular, molecular, and genetic mechanisms known as hallmarks of Alzheimer's. This is true not only for the excessive production in the brain of protein aggregates leading to amyloid plaques and neurofibrillary tangles but also for the clearance of these molecules from the brain parenchyma via the blood-brain barrier and for the escalated process of neuroinflammation-and even for the effects of carrying Alzheimer's-associated genetic variants. Suboptimal TH levels result in a greater accumulation of protein aggregates in the brain. The direct TH regulation of critical genes involved in amyloid beta production and clearance is remarkable, affecting the expression of multiple genes, including APP (related to amyloid beta production), APOE, LRP1, TREM2, AQP4, and ABCB1 (related to amyloid beta clearance). TH also affects microglia by increasing their migration and function and directly regulating the immunosuppressor gene CD73, impacting the immune response of these cells. Studies aiming to understand the mechanisms that could explain how changes in TH levels can contribute to the brain alterations seen in patients with Alzheimer's are ongoing. These studies have potential implications for the management of patients with Alzheimer's and ultimately can contribute to devising new interventions for these conditions.

Potential predictor of prognosis in breast carcinoma: Tumor budding

ABSTRACT Background: Breast cancer is the most common cancer in women, with invasive breast carcinoma of no special type (IBC-NST) accounting for the majority of cases. Aim: This study aimed to evaluate the relationship between tumor budding (TB), which is the earliest histological indicator of tumor spread and represents epithelial–mesenchymal transition, and prognostic factors as well as the effect of TB on survival in patients with IBC-NST, thereby demonstrating its potential prognostic value. Materials and Methods: This study included 278 cases of breast resection diagnosed with IBC-NST from 2014 to 2019. Total tumor buds were counted in 10 high-power fields of a hematoxylin and eosin–stained section with the most infiltrative area at 400× magnification. The cutoff value for TB was obtained using receiver operating characteristic analysis for mortality and recurrence risk; this cutoff value was used to classify TB into two categories: low and high grades. The relationship between TB and prognostic factors and the effect of TB on the survival of patients were investigated. Results: This study revealed a statistically significant relationship between high-grade TB and increased tumor size, advanced pathological primary tumor (pT) category, lymph node metastasis, lymphatic invasion, blood vessel invasion, increased recurrence, and mortality as well as reduced overall and disease-free survival. Conclusion: TB in breast carcinomas may have significant predictive value for prognosis. It emerges as a simple, reproducible, and cost-effective histological marker. With the standardization of evaluation criteria, TB may be readily integrated into routine pathological examination, thereby increasing its value in clinical patient management.

A case of basal cell carcinoma of skin with bone metastasis: a case report

BackgroundBasal cell carcinoma is the most prevalent skin cancer, most characterized by local aggressiveness but with low metastatic potential, and bone metastasis is quite heterogeneous, thus the incidence profile is variable size from 0.0028% to 0.5%. We have this patient with an unusual example of basal cell carcinoma with bone metastases to add to the scarce report on this matter.Case descriptionHere we document a 48-year-old Persian man with a background of being exposed to the sun for a long time. He was diagnosed with an ulcer on the cheek, which was clinically characterized and further confirmed by biopsy as morpheaform basal cell carcinoma. Following the first round of excision, multiple relapses eventually metastasized to the bone. The latter was found on follow-up radiologic scans. This case is characterized by the aggressive nature of the disease and the heterogeneity of basal cell carcinoma growth, thus challenging the conventional view of basal cell carcinoma behavior. Treatment included surgical excision of the primary lesion, which was treated with radiotherapy afterward. However, the skeleton improved slowly during follow-up, and palliative care was eventually pursued to control symptoms and improve quality of life.ConclusionsThis was a rare case of basal cell carcinoma metastasis to non-bone organs, which reminded us to consider basal cell carcinoma metastasis, especially in the case of atypical basal cell carcinoma. Therefore, risk-aware patient management is essential. Moreover, these findings highlight the role of further research into the mechanisms of basal cell carcinoma metastasis, leading to improved therapeutic strategies that may lead to potential improvements in patient outcomes.

Periodontitis: orthodontic implications and management

Orthodontics is increasingly ingrained in the overall management of patients with periodontitis. Advanced periodontitis is often characterised by pathological tooth migration, loss of posterior support and incisal proclination. Orthodontics may therefore offer both aesthetic and therapeutic benefit. A tailored approach to treatment, however, is necessary given the myriad of presentations and associated risk. The nuances underpinning effective treatment planning, space creation, treatment mechanics, and retention in the periodontal patient are described.

Preoperative Structural Risk Factors for Glaucoma After Penetrating Keratoplasty for Congenital Corneal Opacity: An Observational Study.

Post-keratoplasty glaucoma (PKG) is a major complication following penetrating keratoplasty (PKP) for congenital corneal opacity (CCO). This study aims to assess the preoperative structural risk factors for PKG following PKP for CCO using ultrasound biomicroscopy (UBM). Pediatric patients with CCO who underwent preoperative UBM and primary PKP were enrolled. Patients with anterior segment operation history or witha follow-up duration less than 12months were excluded. The structural features of the anterior segment including central corneal thickness, anterior chamber depth, angle closure range (ACR), anterior synechia range, maximum iridocorneal adhesion length, abnormal iridocorneal synechia, and lens anomalies were identified on UBM images. The medical histories were reviewed to identify clinical features. The incidence of PKG was assessed to determine significant structural and clinical risk factors. Fifty-one eyes of 51 pediatric patients with CCO were included. The median age at surgery was 8.0months, and the mean follow-up duration was 33 ± 9months. Eleven (21.6%) eyes developed PKG. The main structural risk factors were abnormal iridocorneal synechia (P = 0.015), lens anomaly (P = 0.001), and larger ACR (P = 0.045). However, a larger range of normal anterior synechia without involvement of the angle was not a significant risk factor. Preoperative glaucoma (P < 0.001) and higher intraocular pressure (P = 0.015) were clinical risk factors. A shallow anterior chamber was a unique risk factor for sclerocornea (P = 0.019). Detailed preoperative examination of iridocorneal synechia, lens, and angle closure using UBM is critical for PKG risk assessment, surgical prognosis evaluation, and postoperative management in patients with CCO.

Optimisation of the diagnosis of Central Nervous System infections in Vietnamese hospitals: Results from a retrospective multicentre study

Abstract Introduction Central nervous system (CNS) infections pose significant health challenges, particularly in low- and middle-income countries (LMICs), due to high morbidity and mortality rates. Rapid and accurate diagnosis is essential for effective treatment to prevent adverse outcomes. Traditional culture-based diagnostics are often slow and lack specificity. This study evaluates the BioFire® FilmArray® Meningitis/Encephalitis (FAME) Panel against standard diagnostics in Vietnam to assess its clinical impact and suitability for local epidemiology. Methods We conducted a prospective study involving 330 patients with suspected CNS infections at four hospitals in northern Vietnam from July 2022 to April 2023. CSF samples were analysed using routine culture methods and FAME. We compared pathogen detection rates and assessed the potential clinical impact of FAME results on patient management. Results Of the 330 CSF specimens, 64 (19%) were positive by either conventional diagnostics (n=48) and/or FAME (n=33). The agreement between FAME and conventional diagnostics was 87%. Key pathogens Mycobacterium tuberculosis (n=7), Klebsiella pneumoniae (n=5), Streptococcus suis (n=5), Epstein-Barr virus (n=3), Acinetobacter baumannii (n=1), and Trichosporon asahii (n=1) were not detected by FAME. Classical meningitis parameters-clinical symptoms, altered glucose, protein, and pleocytosis- were good predictors of FAME positivity, indicating their utility in optimizing local diagnostic algorithms. Conclusion FAME complements traditional diagnostics by offering rapid and broad pathogen detection, crucial for timely and appropriate therapy. However, its effectiveness varies with local epidemiology, and it should not replace conventional methods entirely. Tailoring diagnostic panels to regional pathogen prevalence is recommended to enhance diagnostic accuracy and clinical outcomes in LMICs.

Central nervous system pediatric multi-disciplinary tumor board: a single center experience

BackgroundThe Multidisciplinary Tumor Board (MTB) is a collaborative platform involving specialists in oncology, surgery, radiology, pathology, and radiotherapy, and aims to optimize diagnostics and treatments. Despite MTB’s widespread benefits, limited literature addresses its application in pediatric neuro-oncology. After a literature revision on pediatric neuro-oncology MTB, our study describes our institute’s pediatric neuro-oncology MTB, focuses on evaluating its impact and the neuroradiologist’s role in patient-centric approaches, considering recent genetic insights into pediatric brain tumors.Materials and methodsLiterature Review concerning pediatric neuro-oncology MTB from January 2002 to June 2024. Clinical Data: retrospective study of all patient files presented in the pediatric neuro-oncology MTB (pnMTB) between 2019 and 2022. Statistical analysis was mainly carried out by directly comparing the absolute or relative values of the respective parameters examined; qualitative variables compared mainly with the chi-square test, quantitative variables mainly with the t-test.ResultsLiterature Review: 7 papers encompass a multidisciplinary approach for the pediatric CNS tumors.Clinical dataA total of 236 discussions were analyzed representing 107 patients. Median age was 14,3 years (range: 6 months – 17 years). The requests for case evaluations primarily came from the pediatric oncologists (83%) and neurosurgeons (14.8%), and they were mainly addressed to the neuroradiologists (70.3%). Proposals during pnMTB mainly involved imaging follow-up (47.8%) and management with chemotherapy (34.7%). Changes in patient treatment (CPT) occurred in 115 cases, and pediatric neuroradiologist intervention contributed to 72.4% of these changes.ConclusionThanks to their multidisciplinarity, high number of cases discussed, and usual respect for their proposals, the pnMTB has made it possible to improve the coordination among specialties involved in patient management, to apply the recent protocols, and to exchange knowledge among teams managing pediatric CNS tumors.

Stated Preferences of At-Risk Populations for the Treatment of Osteoporosis: A Systematic Review.

Poor adherence to anti-osteoporosis treatment is a well-recognized problem, partly due to misalignment with patient preferences. In recent years, several quantitative preference studies have been conducted. This study aimed to systematically review stated preference research to provide a comprehensive overview of patient preferences in osteoporosis, in particular on conditional relative attribute importance and preference heterogeneity. This systematic review was conducted in MEDLINE and Embase up to February 29th, 2024. It includes all English-language, peer-reviewed, stated preference articles related to osteoporosis management and treatment in patients with or at risk of osteoporosis. Conditional relative importance of attributes as well as heterogeneity was assessed, and attributes classified into outcome, process, and cost attributes. Quality assessment was performed using a combined checklist of Purpose, Respondents, Explanation, Findings, and Significance (PREFS) and International Society for Pharmacoeconomics and Outcomes Research (ISPOR) items. Fourteen studies including 4714 participants were evaluated. Attributes were mostly classified as process related (50%) and outcome related (40%), both of which significantly influence patient preferences. In pairwise attribute comparison, efficacy was dominant over cost, administration, and side-effects. Preference heterogeneity was observed in the majority of studies (86%). Quality assessment indicated an overall improvement in study quality over time, with recent studies adhering more closely to established methodological standards. The findings highlight the importance of considering patient preferences in the management of osteoporosis, underscoring the need for a patient-centered approach. The readiness of patients to engage in trade-offs between attributes suggests that healthcare providers should ensure treatments are aligned with individual patient preferences to improve adherence and optimize outcomes.